Sleep apnoea in surgery

Dr Stavros Memtsoudis, director of Critical Care Services at Hospital for Special Surgery. Credit: Hospital for Special Surgery.

Although as many as 25 percent of patients undergoing surgery suffer from sleep apnoea, few hospitals have policies to help manage the risks of this condition during surgery, and there is little evidence to help guide anaesthetists and surgeons caring for these patients. Published in the New England Journal of Medicine, Stavros Memtsoudis, MD, PhD, director of Critical Care Services at Hospital for Special Surgery, New York City, calls for a new research initiative to identify the safest and most effective ways to manage patients with sleep apnoea.

Sleep apnoea not only makes for a restless night but also puts the person at increased risk of high blood pressure, diabetes, heart attack and stroke. But although the condition is more common than diabetes, and poses particular hazards during surgery, relatively little research has been done to help guide clinicians.

“Patients with sleep apnoea may be at risk of many complications during surgery, including airway blockage and intubation problems,” said Dr Memtsoudis. “But that’s not all: we know that apnoea affects many other organ systems as well. The American Society of Anesthesiologists published guidelines in 2006 to help us take better care of patients with sleep apnoea, but there was – and still is – very little research to support these recommendations.”

The current guidelines recommend a period of pre-operative evaluation for patients with sleep apnoea; the use of continuous positive airway pressure (CPAP); the use of local or regional anaesthesia or peri-operative nerve blocks rather than general anaesthesia; and extended periods of observation of the patient during the post-surgical period. “But there is insufficient evidence to tell us whether these actions actually have any effect,” said Dr Memtsoudis. “And as we continue to see an increase in the number of surgical patients with sleep apnoea, it creates a significant financial burden for hospitals at a time when healthcare costs are skyrocketing.”

In May, Dr Memtsoudis published the first study to date that provides evidence about specific techniques for the safe management of patients with sleep apnoea surrounding surgery. That study found that the use of regional anaesthesia, rather than general anaesthesia, reduced major complications by 17 percent in patients with sleep apnoea undergoing joint surgery.

“We need much more research like this,” he said.

Working with key members of the new Society for Anesthesia and Sleep Medicine, Dr Memtsoudis and his colleagues from the Department of Public Health at Cornell University are now designing a multicenter ‘practice-based evidence’ study that will collect data from institutions that have varying practices with regard to the management of sleep apnoea in surgical patients. “This will help us assess what works and what doesn’t work and who among sleep apnoea patients is actually at risk,” he said. “We can’t just advocate that people keep doing what they’re doing with no evidence for it.”